Assessing, Diagnosing, and Treating Adults With Mood Disorders

Focused SOAP Note
Subjective:
CC (chief complaint): The patient seeks mental health assessment based on her history of taking mental health medication. Her major problem is that she often stops taking medication because they interfere with her normal functioning. In her words, she says that the medication squashes who she is; in terms of creativity, alertness, and sleep.
HPI: The patient’s name is Petunia Park (PP). She is white and 26 years old (born in 1995). She reports that she has been admitted to the hospital four times due to mental health problems. The first time she was hospitalized, she had up to 5 days without sleeping. In 2017, following a Benadryl overdose, she was hospitalized for attempted suicide, a period in which she experienced hearing voices telling her she was awesome. Further, PP reports that she has been diagnosed with anxiety, depression, and bipolar before. She has been on several medications since then. These medications, she reports, have affected her negatively. For instance, Zoloft made her feel high and lose sleep, risperidone and Seroquel caused her to gain weight, while Klonopin made her feel slow. Another drug that PP was unable to identify squashed her creativity.
PP further reports that she experiences an annual cycle(s) of periods of creativity in which she engages in writing and painting and gets most of her work done while eating, having sex, and sleeping less, followed by periods of self-loathing, long sleeping hours (12-16 hours per day), and increased appetite. Typically, she gets 5 to 6 hours of sleep in 24 hours. However, she sleeps only three hours a week during her creativity episodes. PP denies having suicidal thoughts or hallucinogenic experiences. PP lives with her boyfriend, but she is sometimes forced to stay with her mother because of her promiscuous behavior. She works part-time in her Aunt’s bookstore but misses work sometimes due to depression. She has no children, and she has never been married. She is currently in a vocational school pursuing cosmetology and dreams of making up for movie stars. She idolizes Picasso and enjoys writing her life story, which she thinks will be published.
FAMILY HISTORY: Like PP, her mother had attempted suicide before, which was unsuccessful. The mother has also been diagnosed with bipolar disorder. Her father has been in prison for drugs, and PP has never seen him in over eight years. PP also reports that her brother has mental issues (schizo) but has not been diagnosed or sought treatment.
Substance Current Use: Currently, the client smokes about a pack of cigarettes per day but hates alcohol and has only tried marijuana once in her life.
Medical History:
Current Medications: While the client has sex with different partners more often, she reports being safe from pregnancy. She has stopped all her mental health medication. Thus, she is only on birth control at the moment. Birth control is for polycystic ovarian disease.
Allergies: PP did not report any allergies.
Reproductive Hx: The client reported regular menses with the last menses one month ago.
ROS:
GENERAL: The patient report periodic changes in appetite.
HEENT: The patient denies any form of hallucination.
GENITOURINARY: The p...